Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial

Implementation of uterine artery embolization for symptomatic fibroids in the Netherlands: an inventory and preference study

Background and purpose

The Dutch national guideline on heavy menstrual bleeding was updated and published in 2013. It recommended (for the first time) that uterine artery embolization (UAE) should be part of counseling of women with symptomatic fibroids. We aimed to evaluate the implementation of UAE for symptomatic uterine fibroids in the Netherlands and to investigate gynecologists preference and other influential factors.

Methods

The primary outcome was to examine the UAE/hysterectomy ratio before and after introduction of the 2013 guideline by the use of annual hospital reports. The secondary outcome assessed factors that could influence implementation by means of a questionnaire to gynecologists.

Results

A total of 29/30 (97%) UAE+ hospitals and 36/52 (69%) UAE- hospitals sent their annual reports. The UAE/hysterectomy percentages in 2012, 2013 and 2014 were 7,0%, 7.0% and 6.9%, respectively. Regarding the questionnaire, the response rates were 88% and 91%, respectively. In both groups we observed a high self-perceived tendency for UAE counseling (90% versus 70%, p = .001). Approximately 50% of gynecologists from UAE- hospitals indicate they have insufficient information about UAE for appropriate counseling and 40% doubts the effectiveness of UAE. Furthermore, in the majority of gynecologists some ‘urban myths’ about the effectiveness and side-effects of UAE seem to persevere.

Conclusion

Adding UAE as a treatment option to the national guideline did not change the number of performed UAEs for symptomatic fibroids. It might be useful to develop an option grid in order to offer appropriate, independent counseling and encourage shared decision making.

Electronic supplementary material

The online version of this article (10.1186/s42155-019-0061-5) contains supplementary material, which is available to authorized users.

Uterine Artery Embolization in Patients With Autoimmune Disease: A Matched Case-Control Study

OBJECTIVE. The purpose of this study is to investigate the safety of uterine artery embolization (UAE) for symptomatic leiomyomas in patients with autoimmune disease. MATERIALS AND METHODS. Of 1183 patients who underwent UAE for symptomatic leiomyomas, nine patients (mean age, 42.6 years; range, 34-49 years) with autoimmune disease were included in this study. An age- and disease-matched control group (n = 8) was randomly generated from our patient registry to compare the effectiveness and safety of UAE in patients with autoimmune disease. Volume reduction rates of the uterus and dominant leiomyoma and the change in C-reactive protein (CRP) levels before and after UAE were compared. RESULTS. Except for one patient who had Takayasu arteritis and indiscernible uterine arteries on angiogram, UAE was technically successful in both groups. All of the patients who underwent technically successful UAE experienced improvement or resolution of symptoms (16/16; 100%). Complete necrosis of dominant fibroids was achieved in all patients (16/16; 100%). Although there was no significant difference in the mean initial CRP level before UAE (0.4 ± 0.14 mg/L vs 1.06 ± 1.26 mg/L; p = 0.067), it was significantly higher in the autoimmune group 1 day after UAE (1.23 ± 0.6 mg/L vs 9.54 ± 6.63 mg/L; p = 0.001). There was no significant difference in the volume reduction rates of uterus and dominant leiomyoma. In the autoimmune group, there was one major adverse event that was not related to underlying disease. CONCLUSION. In patients with autoimmune disease, UAE could be considered for symptomatic leiomyomas, as long as the underlying disease is well controlled.

Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy

Adenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age. To date, many aspects of the disease have not been fully understood, making management increasingly difficult. Over time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine preservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now available, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-intensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established treatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for treatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the management of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to hysterectomy.

Patient-reported outcome measures in benign gynecologic surgery: updates and selected tools

PURPOSE OF REVIEW

Use of patient-reported outcome measures in clinical practice and research is becoming more prevalent and reflects initiatives to center the patient in healthcare delivery and outcomes assessment. The purpose of this review is to provide a summary description of selected, validated tools used to assess outcomes related to several benign gynecologic conditions: abnormal uterine bleeding, fibroids and endometriosis.

RECENT FINDINGS

Given the availability of several validated instruments to assess patient outcomes in benign gynecology, there is still significant heterogeneity in tools used in trials.

SUMMARY

Patient outcomes assessment should be an integral part of clinical practice and research in order to treat the whole patient and address any health-related impacts on quality of life. More attention is needed to increase standardization of tools used in research to facilitate assessment of comparative efficacy between treatments.

Robotic myomectomy for large uterine myomas

OBJECTIVE

To evaluate surgical outcomes and feasibility of robotic myomectomy in large uterine myomas.

MATERIALS AND METHODS

This is a retrospective study for robotic myomectomies performed from October 2012 to August 2017 by a single surgeon in a tertiary care referral hospital. Demographics, diagnosis, perioperative variables, operative outcomes and complications were recorded. Large uterine myoma was defined as the estimated diameter of dominant myoma equal to or larger than 10 cm by sonography.

RESULTS

Seventy-four patients were included and 32 (43.2%) patients had large uterine myoma. Patients with myoma larger than 10 cm showed significantly heavier myoma weight (446.5 ± 206.2 mg vs. 288.1 ± 147.5, p < 0.001), similar blood loss (309.4 ± 190.3 mL vs. 200.9 ± 285.9 mL, p = 0.06), and longer operative time (263.4 ± 83.7 min vs. 219.1 ± 75.7 min, p = 0.02) compared with patients with myoma <10 cm. The largest myoma removed was 20 cm in diameter. Perioperative complications were rare.

CONCLUSION

Robotic myomectomy is feasible for managing large uterine myomas. It is a safe procedure with acceptable longer operative time.

FIRSTT study: randomized controlled trial of uterine artery embolization vs focused ultrasound surgery

BACKGROUND

Uterine leiomyomas (fibroid tumors) cause considerable symptoms in 30-50% of women and are the leading cause of hysterectomy in the United States. Women with uterine fibroid tumors often seek uterine-preserving treatments, but comparative effectiveness trials are lacking.

OBJECTIVE

The purpose of this study was to report treatment effectiveness and ovarian function after uterine artery embolization vs magnetic resonance imaging-guided focused ultrasound surgery from the Fibroid Interventions: Reducing Symptoms Today and Tomorrow study.

STUDY DESIGN

The Fibroid Interventions: Reducing Symptoms Today and Tomorrow study, which is a randomized controlled trial of uterine artery embolization vs magnetic resonance imaging-guided focused ultrasound surgery, enrolled premenopausal women with symptomatic uterine fibroid tumors; women who declined randomization were enrolled in a parallel observational cohort. A comprehensive cohort design was used for outcomes analysis. Our target enrollment was 220 women, of which we achieved 41% (n=91) in the randomized and parallel arms of the trial. Primary outcome was reintervention for uterine fibroid tumors within 36 months. Secondary outcomes were change in serum anti-Müllerian hormone levels and standardized measures of fibroid symptoms, quality of life, pain, and sexual function.

RESULTS

From 2010-2014, 83 women (mean age, 44.4 years) were treated in the comprehensive cohort design (43 for magnetic resonance imaging-guided focused ultrasound surgery [27 randomized]; 40 for uterine artery embolization [22 randomized]); baseline clinical and uterine characteristics were similar between treatment arms, except for higher fibroid load in the uterine artery embolization arm. The risk of reintervention was higher with magnetic resonance imaging-guided focused ultrasound surgery than uterine artery embolization (hazard ratio, 2.81; 95% confidence interval, 1.01-7.79). Uterine artery embolization showed a significantly greater absolute decrease in anti-Müllerian hormone levels at 24 months compared with magnetic resonance imaging-guided focused ultrasound surgery. Quality of life and pain scores improved in both arms but to a greater extent in the uterine artery embolization arm. Higher pretreatment anti-Müllerian hormone level and younger age at treatment increased the overall risk of reintervention.

CONCLUSION

Our study demonstrates a lower reintervention rate and greater improvement in symptoms after uterine artery embolization, although some of the effectiveness may come through impairment of ovarian reserve. Both pretreatment anti-Müllerian hormone level and age are associated with risk of reintervention.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00995878, clinicaltrials.gov.

Uterine artery embolization in the treatment of symptomatic fibroids - state of the art 2018

Uterine fibroids are considered to be the most common benign tumours in females. The vast majority of these tumours are incidental findings and do not require any treatment. Symptomatic fibroids, with ailments such as abnormal uterine bleeding, dysmenorrhoea, pelvic pain, impaired urination, bowel dysfunction, infertility, and recurrent pregnancy loss, are indicated for medical treatment. Surgery remains a first-line treatment of symptomatic uterine fibroids; however, minimally invasive techniques and pharmacological management have become more available and popular. Among minimally invasive techniques uterine artery embolization (UAE) is the most well-established uterine preserving treatment. UAE was first introduced in obstetrics and gynaecology in 1987 and since then many studies have shown the safety and efficacy of UAE in fibroid treatment with low rates of complications. In this review we present a novel approach to UAE, which reflects the current state of knowledge based on recent clinical trials and long-term post-procedural follow-up.

Five-year clinical outcomes of uterine artery embolization for symptomatic leiomyomas: An analysis of risk factors for reintervention

OBJECTIVES

The objective of this study is to investigate the five-year reintervention rate of uterine artery embolization (UAE) for symptomatic leiomyomas and to identify potential predictive factors of reintervention.

METHODS

From March 2011 to February 2012, 92 consecutive women (mean age 41.9 years, range 28-55 years) underwent bilateral UAE. Contrast-enhanced magnetic resonance imaging (MRI) was performed at three-month follow-up. After annual follow-up, a survey on clinical outcome and reintervention incidences was performed at five-year follow-up. Potential predictive factors of reintervention were evaluated.

RESULTS

Of the 67 patients, menorrhagia and/or bulk-related symptoms were resolved after UAE in all but one patient (98.5%). At median follow-up of 60 months (range, 5-60 months), reintervention rate was 10.4%, with seven reintervention cases (five myomectomy and two hysterectomy cases). Complete (100%) or near complete (90-99%) infarction rate of the dominant leiomyoma was 96.4% (54 of 56). Independent factors of reintervention on multivariate logistics regression analysis included near complete or partial (<90%) infarction of the dominant leiomyoma (odds ratio [OR] 22.238; 95% confidence interval [CI] 2.405-205.620; p = 0.006), as well as the presence of non-dominant viable leiomyomas (OR 12.134; 95% CI 1.213-121.409; p = 0.034).

CONCLUSION

UAE provides excellent and sustained symptom improvement of symptomatic leiomyomas with a low reintervention rate at five-year follow-up. In addition to near complete or partial infarction of the dominant leiomyoma on follow-up MRI, the presence of viable non-dominant leiomyomas indicates a higher risk of reintervention.

Uterine Artery Embolization in Women with Symptomatic Cervical Leiomyomata: Efficacy and Safety

Purpose

To perform an evaluation on safety and efficacy of uterine artery embolization (UAE) in the patients with symptomatic cervical leiomyomata.

Methods

Patients with symptomatic cervical leiomyomata who underwent UAE in one specialized hospital were retrospectively analyzed, both clinically and with MR imaging. The 3-month outcomes were assessed with MR imaging and a validated questionnaire. Long-term follow-up was assessed by direct contact or file review. To determine the efficacy of UAE for cervical leiomyomata, the primary objective was to assess the clinical outcome with the UFS-QOL questionnaire, containing the health-related quality of life (HRQOL) and symptom severity score (SSS). To assess safety, the secondary objective included leiomyomata volume reduction, the infarction/complication rate and secondary interventions were needed.

Results

Between 2006 and 2017, eight of 1180 patients underwent UAE and were eligible for inclusion. All embolizations were technically successful (n = 8). At 3 months, all patients showed cervical leiomyomata volume reduction with a median reduction of 41.5% (38.8 cm³) compared to baseline (p = 0.012). No complications occurred. At a median follow-up of 3 months (range 1–7, n = 7), the HRQOL and SSS improved with a median difference of 13 points (range − 5 to 60, p = 0.063) and − 13 points (range − 79 to 3, p = 0.046), respectively. Long-term follow-up showed two secondary interventions (median of 43.5 months). Six patients reported no symptom recurrence.

Conclusion

UAE in women with symptomatic cervical leiomyomata is effective and safe with significant improvement in symptoms and quality of life. UAE is a valuable option for women seeking a non-surgical solution.

Electronic supplementary material

The online version of this article (10.1007/s00270-018-2081-2) contains supplementary material, which is available to authorized users.

Uterine artery embolization in a sheep model: biodegradable versus non-degradable microspheres

Background Transarterial embolization with particles is a relatively common treatment method in both malignant and benign disorders. Permanent occlusion of the uterine arteries may sometimes be disadvantageous. Purpose To compare the local tissue effects, possible side effects, and extent of recanalization following uterine artery embolization, using either degradable or non-degradable microspheres in a sheep model. Material and Methods In 22 female sheep, the uterine artery (UA) was unilaterally, superselectively embolized, with either degradable starch microspheres-DSM (group A) or calibrated gelatin coated spherical shape tris-acryl microspheres-TGMS (group B). The completion of embolization was confirmed by angiography. The animals were kept in the animal research facilities for 14 days and sacrificed following new angiographic evaluation. Gross and histological examination of the uterus and other organs was performed. Results The procedure was successful in all animals. At final angiographic evaluation recanalization was found in 82% of the ewes in group A and in 18% in group B. At histopathological examination, tissue impairment was similar in both groups, whereas vascular changes were more pronounced in the TGMS-group. Conclusion Embolization with DSM was associated with significantly higher degree of recanalization, than after embolization with TGMS.

The rationale, design, and methods of a randomized, controlled trial to evaluate the efficacy of single-dose dexamethasone in reducing post-embolization syndrome in patients undergoing uterine artery embolization

Background

Uterine artery embolization (UAE) is a minimally invasive technique well established for treating symptomatic uterine fibroids. However, the post-procedure recovery for UAE involves a notable inflammatory process in response to ischemia known as post-embolization syndrome (PES). PES encompasses transient leukocytosis, low-grade fever, and can result in readmission of up to 10% of patients. In surgical settings, multiple studies have demonstrated the efficacy of glucocorticoids in reducing inflammation and associated pain. However, this approach has not yet been assessed in predominantly ischemia-driven PES.

Methods

This paper describes the protocol of a prospective randomized, double-blind, placebo-controlled, multi-center trial to test the efficacy and safety of single-dose dexamethasone on inflammatory responses, pain, nausea, and readmission rates after UAE. The study will enroll pre-menopausal patients between 25 and 55 years (planned enrollment, n = 60) with MRI confirmed symptomatic fibroids. Patients will be randomly allocated into two groups: single-dose intravenous dexamethasone plus standard of care or placebo (normal saline) plus standard of care.

Results

The primary endpoint is the patient pain score 4 h following the UAE procedure. Secondary endpoints include pain scores at 7 h and 24 h following UAE; narcotic usage in the first 24 h following UAE; and serum inflammatory markers (white blood cell count, C-reactive protein [CRP], interleukin-6 [IL-6], and cortisol) 24 h after UAE.

Conclusion

Given the high incidence of post-procedure pain and difficulty with pain control after uterine artery embolization, results of this trial may directly influence the standard of care in perioperative management of patients undergoing UAE.

Comparison of the influence of three fibroid treatment options: supracervical hysterectomy, ulipristal acetate and uterine artery embolization on ovarian reserve - an observational study

BACKGROUND

To assess and compare the influence of three fibroid treatment options: supracervical hysterectomy, ulipristal acetate and uterine artery embolization on ovarian reserve.

METHODS

Prospective, observational, open-label study performed at the 3rd Chair and Department of Gynecology of the Medical University of Lublin, Poland. Premenopausal Caucasian women with symptomatic uterine fibroids were recruited into 3 groupspatients qualified for supracervical hysterectomies; patients qualified for preoperative ulipristal acetate (UPA) treatment scheduled for supracervical hysterectomies or myomectomies; patients qualified for uterine artery embolization (UAE). The following markers of ovarian reserve were investigated: antral follicle count (AFC), anti-Mullerian hormone (AMH), inhibin B (INHB), follicle stimulating hormone (FSH) and estradiol (E2). These markers were assessed before and 3 months after supracervical hysterectomies, before and 3 months after UAEs, and before and after 3 months of UPA treatment, before the scheduled surgeries. Baseline characteristics (age, parity, dominant fibroid volume, hemoglobin level, BMI, as well as AFC, AMH, INHB, FSH and E2) were compared between the study groups by Kruskall-Wallis ANOVA. Pre- and post-interventional values of AFC, AMH, INHB, FSH and E2 in the studied groups were compared with the Wilcoxon matched pairs test.

RESULTS

Twenty-six, 27 and 30 patients were included in the final analysis in the supracervical hysterectomy, UPA and UAE groups, respectively. Three months after supracervical hysterectomy INHB and E2 significantly decreased, while AFC, AMH and FSH remained unchanged. After 3 months of UPA treatment the values of all the assessed markers of ovarian reserve were not significantly different in comparison to baseline. Conversely, three months after UAE the values of AFC, AMH, INHB, and E2 were significantly decreased, while FSH was significantly increased.

CONCLUSIONS

Of the compared fibroid treatment methods UAE seems to have the greatest impact on ovarian function and should not be offered to patients concerned about their ovarian function. Supracervical hysterectomy did not affect the most accurate markers of ovarian reserve, and therefore appears to be safe in terms of ovarian function. UPA did not change any of the studied markers of ovarian reserve and seems a reasonable option when ovarian function is concerned.

An Academic Tertiary Referral Center's Experience with a Vascular Surgery-Based Uterine Artery Embolization Program

BACKGROUND

Despite growing endovascular experience within the vascular surgery community, some catheter-based interventions-such as uterine artery embolization (UAE)-remain outside the clinical scope of most vascular surgeons, owing in part to established referral patterns and limited awareness among referring colleagues. We present our experience with a vascular surgery-based, multidisciplinary UAE program at an academic tertiary referral center.

METHODS

In a collaborative effort between vascular surgeons and gynecologists, a pelvic vascular disease program has been established to provide palliative, prophylactic, and therapeutic embolizations including, but not limited to, UAE. For UAE, inclusion criteria are women over the age of 18 years with symptomatic uterine fibroids demonstrated on magnetic resonance imaging and a negative endometrial biopsy. Exclusion criteria are desire for future pregnancy and previous embolization(s). Technique and perioperative protocol is presented. Data including symptom resolution, reintervention rates, and complications were prospectively gathered and retrospectively reviewed.

RESULTS

Over an 18-month period, 30 patients with symptomatic fibroids were referred for potential UAE. Five patients were excluded because of uncertainty about future pregnancy wishes (4) and prior embolization (1). Twenty-four bilateral and 2 unilateral UAEs were performed (mean age, 46.3 years [range 28-53 years]). Presenting symptoms were pelvic and abdominal pain (25), cramps (25), menorrhagia (25), dysmenorrhea (25), urinary frequency (12), and dyspareunia (5). Technical success, defined as successful microcatheterization of uterine arteries and delivery of a particulate liquid embolic agent (embospheres, 500-700 microns), was 100%. There were no perioperative or delayed complications. Twenty-one patients (87.5%) reported complete symptomatic relief without further intervention at the time of last follow-up. Three patients (12.5%) reported pain relief but had persistent vaginal bleeding requiring hysterectomy 12 months after UAE. All patients underwent a 23-hr observation postoperatively for pain control. Mean follow-up was 7.4 months (1-23 months) and included pelvic ultrasound assessment of fibroid size at 1, 3, and 6 months after UAE and annually thereafter. One patient was lost to follow-up. Fibroid shrinkage was noted in all patients. Given the willingness and capability to work-up, admit, treat, and follow-up patients, vascular surgery was deemed the preferred service for UAE by the referring gynecologists.

CONCLUSION

Within the framework of a collaborative, multidisciplinary program, vascular surgery can play a prominent role in providing safe and effective UAE.

Uterine Artery Embolization Versus Hysterectomy in the Treatment of Symptomatic Adenomyosis: Protocol for the Randomized QUESTA Trial

Background

Adenomyosis is a benign uterine disease characterized by invasion of endometrium into the myometrium resulting in heavy menstrual bleeding and pain (dysmenorrhea). Hysterectomy is established as the final treatment option when conservative treatment fails. Uterine artery embolization (UAE) in patients with symptomatic adenomyosis has demonstrated to reduce symptoms and improve quality of life. However, randomized controlled trials are lacking.

Objective

With this study, we aim to evaluate the impact of UAE on Health-Related Quality of Life (HRQOL) in a randomized comparison to hysterectomy in patients with symptomatic adenomyosis.

Methods

This is a multicenter non-blinded randomized controlled trial comparing UAE and hysterectomy. Eligible patients are symptomatic premenopausal women without the desire to conceive and who have symptomatic magnetic resonance imaging (MRI)–confirmed pure adenomyosis or dominant adenomyosis accompanied by fibroids. After obtaining informed consent, patients will be randomly allocated to treatment in a 2:1 UAE versus hysterectomy ratio. The primary objective is HRQOL at 6 months following the assigned intervention. Secondary outcomes are technical results, pain management, clinical outcomes, HRQOL, and cost effectiveness during 2 years of follow-up. In addition, transvaginal ultrasound (TVUS) and MRI will be performed at regular intervals after UAE.

Results

Patient enrollment started November 2015. The follow-up period will be completed two years after inclusion of the last patient. At the time of submission of this article, data cleaning and analyses have not yet started.

Conclusions

This trial will provide insight for caretakers and future patients about the effect of UAE compared to the gold standard hysterectomy in the treatment of symptomatic adenomyosis and is therefore expected to improve patients’ wellbeing and quality of life.

Trial Registration

Netherlands Trial Register NTR5615; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5615 (Archived by WebCite at http://www.webcitation.org/6xZRyXeIF)

Pelvic Blood Flow Predicts Fibroid Volume and Embolic Required for Uterine Fibroid Embolization: A Pilot Study With 4D Flow MR Angiography

OBJECTIVE

We report here an initial experience using 4D flow MRI in pelvic imaging-specifically, in imaging uterine fibroids. We hypothesized that blood flow might correlate with fibroid volume and that quantifying blood flow might help to predict the amount of embolic required to achieve stasis at subsequent uterine fibroid embolization (UFE).

MATERIALS AND METHODS

Thirty-three patients with uterine fibroids and seven control subjects underwent pelvic MRI with 4D flow imaging. Of the patients with fibroids, 10 underwent 4D flow imaging before UFE and seven after UFE; in the remaining 16 patients with fibroids, UFE had yet to be performed. Four-dimensional flow measurements were performed using Arterys CV Flow. The flow fraction of the internal iliac artery was expressed as the ratio of internal iliac artery flow to external iliac artery flow and was compared between groups. The flow ratios between the internal iliac arteries on each side were calculated. Fibroid volume versus internal iliac flow fraction, embolic volume versus internal iliac flow fraction, and embolic volume ratio between sides versus the ratio of internal iliac artery flows between sides were compared.

RESULTS

The mean internal iliac flow fraction was significantly higher in the 26 patients who underwent imaging before UFE (mean ± standard error, 0.78 ± 0.06) than in the seven patients who underwent imaging after UFE (0.48 ± 0.07, p < 0.01) and in the seven control patients without fibroids (0.48 ± 0.08, p < 0.0001). The internal iliac flow fraction correlated well with fibroid volumes before UFE (r = 0.7754, p < 0.0001) and did not correlate with fibroid volumes after UFE (r = -0.3051, p = 0.51). The ratio of embolic required to achieve stasis between sides showed a modest correlation with the ratio of internal iliac flow (r = 0.6776, p = 0.03).

CONCLUSION

Internal iliac flow measured by 4D flow MRI correlates with fibroid volume and is predictive of the ratio of embolic required to achieve stasis on each side at subsequent UFE and may be useful for preprocedural evaluation of patients with uterine fibroids.

Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis

The effect of uterine artery embolization (UAE) on symptomatic adenomyosis was evaluated in a systematic review and meta-analysis. Four groups were evaluated: short-term (< 12 months) pure adenomyosis, short-term adenomyosis with fibroids (combined adenomyosis), long-term (> 12 months) pure adenomyosis, and long-term combined adenomyosis. Improvement of symptoms occurred in 83.1% (872/1,049) of patients. Reported symptom reduction was 4.8% greater in the short-term combined group (P = .169) and 11.4% greater in the long-term combined group (P = .003). Uterine volume was reduced in all patients at 3 months. The effects of UAE on symptom improvement and uterine volume reduction in patients with adenomyosis are encouraging.

Uterine artery embolization: A review of current concepts

Uterine artery embolization (UAE) has gained traction as a safe and effective treatment modality for symptomatic uterine leiomyomata since its introduction nearly two decades ago. This review includes an overview of current concepts with regard to patient selection, technique, and outcomes following UAE. Specific topics also include the impact of this procedure on fertility and pregnancy, the emerging role of UAE in the treatment of adenomyosis, and how UAE compares with surgical intervention for the treatment of symptomatic leiomyomata.

Temporary Anorgasmia Following Uterine Artery Embolization for Symptomatic Uterine Fibroids

We report a rare case of temporary anorgasmia following uterine artery embolization (UAE) performed for symptomatic uterine fibroids. To our knowledge, this is only the second time that this complication has been reported in the literature. We briefly explore the possible pathophysiologic explanations for this complication and review the effects of UAE compared to hysterectomy on sexual functioning in women.

Unique Learning System for Uterine Artery Embolization for Symptomatic Myoma and Adenomyosis for Obstetrician-Gynecologists in Cooperation with Interventional Radiologists: Evaluation of UAE From the Point of View of Gynecologists Who Perform UAE

STUDY OBJECTIVE

To evaluate a unique learning system for uterine artery embolization (UAE) and examine its feasibility and clinical outcomes for the treatment of symptomatic uterine leiomyomas and adenomyosis when performed by obstetrician-gynecologists in cooperation with interventional radiologists (IVRs).

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

One hundred seventy-three patients who underwent UAE for symptomatic leiomyomas and adenomyosis.

INTERVENTIONS

We examined the medical records of patients who underwent UAE for symptomatic uterine leiomyomas and adenomyosis at our department between 2003 and 2012 using our learning system for UAE for obstetrician-gynecologists in cooperation with IVRs. The charts of all patients were reviewed, and data on etiologic factors, past medical history of leiomyomas and adenomyosis, symptoms, details of UAE, and clinical outcomes after UAE were extracted.

MEASUREMENTS AND MAIN RESULTS

A total of 173 patients who underwent 177 UAEs were identified, including 4 patients who underwent embolization twice because of primary treatment failure or symptom recurrence. During the study period, 2 gynecologists successfully acquired endovascular skills. The technical success rate was 97.7% (174 of 177). The duration of fluoroscopy in procedures performed by obstetrician-gynecologists who acquired endovascular skills was not significantly different from that in procedures performed by IVRs at our institution; however, this duration was significantly longer in procedures performed by obstetrician-gynecologists who did not have sufficient experience with our learning protocol for UAE because of inadequate live observation of UAEs performed by skilled IVRs. Complications that necessitated discontinuation of the procedure occurred in 2.3% of cases (4 of 177). The clinical outcomes were similar to those reported in previous studies. Adverse events after UAE included myeloid passages in 7.0% (11 of 158), infections in 2.5% (4 of 158), vaginal discharge in 2.5% of patients with leiomyomas (4 of 158), and vaginal discharge in 7.1% of patients with adenomyosis (1 of 14). All the adverse events were adequately treated by the obstetrician-gynecologists themselves. The timing of hysterectomy due to complications or recurrence of symptoms after UAE varied widely.

CONCLUSION

UAE performed by obstetrician-gynecologists in cooperation with radiologists can be achieved safely and successfully with acceptable clinical outcomes. Live observation of the procedure performed by skilled IVRs is essential to improving the skills and reducing the fluoroscopic time of obstetrician-gynecologists.

Uterine Artery Embolization for Symptomatic Adenomyosis: 7-Year Clinical Follow-up Using UFS-Qol Questionnaire

PURPOSE

The purpose of this study was to assess clinical outcomes 7 years after uterine artery embolization (UAE) in the treatment of symptomatic adenomyosis.

MATERIALS AND METHODS

In this prospective cohort study, one specialized hospital in the Netherlands recruited patients with symptomatic adenomyosis or adenomyosis in combination with fibroids for UAE. The 7-year post-intervention outcomes were health-related quality of life (HRQOL), symptom severity scores (SSS), satisfaction, menopause and re-interventions.

RESULTS

Twenty-nine patients with adenomyosis (15 with fibroids) were treated with UAE between September 2006 and January 2010. The 7-year questionnaire was mailed in November 2016. The mean follow-up was 95 months (SD 9.0) at a mean age of 50 (SD 5.4). Questionnaires were returned by 24/29 patients (83%). The remaining five patients were contacted through telephone. One of these patients was untraceable. Seven years after treatment 5 of 28 patients (18%) underwent a secondary hysterectomy. The HRQOL and SSS scores as measured by UFS-QOL at 3 months after UAE showed significant improvement of -57 points (score: 15) and +40 points (score: 91), respectively. These scores remained comparable stable up unto 7 years. The SSS showed a significant difference of 17 points (0-100) in favor of the adenomyosis in combination with fibroids group (p = 0.020). Menopause was reported by 10/28 patients (36%). Twenty-one of 29 (72%) patients declared to be at least fairly satisfied about UAE.

CONCLUSIONS

After 7 years of follow-up, in 82% of UAE-treated patients with symptomatic adenomyosis a hysterectomy was avoided.

Robot-assisted laparoscopic myomectomy: current status

Robotic-assisted surgery has seen a rapid development and integration in the field of gynecology. Since the approval of the use of robot for gynecological surgery and considering its several advantages over conventional laparoscopy, it has been widely incorporated especially in the field of reproductive surgery. Uterine fibroids are the most common benign tumors of the female reproductive tract. Many reproductive-aged women with this condition demand uterine-sparing surgery to preserve their fertility. Myomectomy, the surgical excision of uterine fibroids, remains the only surgical management option for fibroids that entails preservation of fertility. In this review, we focus on the role of robotic-assisted laparoscopic myomectomy and its current status, in comparison with other alternative approaches for myomectomy, including open, hysteroscopic, and traditional laparoscopic techniques. Several different surgical techniques have been demonstrated for robotic myomectomy. This review endeavors to share and describe our surgical experience of using the standard laparoscopic equipment for robotic-assisted myomectomy, together with the da Vinci Robot system. For the ideal surgical candidate, robotic-assisted myomectomy is a safe minimally invasive surgical procedure that can be offered as an alternative to open surgery. The advantages of using the robot system compared to open myomectomy include a shorter length of hospital stay, less postoperative pain and analgesic use, faster return to normal activities, more rapid return of the bowel function, and enhanced cosmetic results due to smaller skin incision sizes. Some of the disadvantages of this technique include high costs of the robotic surgical system and equipment, the steep learning curve of this novel system, and prolonged operative and anesthesia times. Robotic technology is a novel and innovative minimally invasive approach with demonstrated feasibility in gynecological and reproductive surgery. This technology is expected to take the lead in gynecological surgery in the upcoming decade.